Development, Implementation, Evaluation, and Long-Term Outcome of a Program to Increase Student Interest in Anesthesia and Intensive Care Training

Development, Implementation, Evaluation, and Long-Term Outcome of a Program to Increase Student Interest in Anesthesia and Intensive Care Training

Experimental and Clinical Transplantation.

Abstract

Objec­tives: The increas­ing need for anes­thetists has been cou­pled with a ris­ing num­ber of open train­ing posi­tions. Thus, there is an increased need to attract future anes­thetists among stu­dents and grad­u­ates from med­ical uni­ver­si­ties. Using results from a ques­tion­naire, we designed an infor­ma­tion and train­ing pro­gram to increase inter­est in anes­the­sia and inten­sive care.
Mate­ri­als and Meth­ods: With the use of semi­struc­tured inter­views, med­ical stu­dents were ques­tioned about fac­tors influ­enc­ing their deci­sion for a spe­cial­i­ty. We used the results to design an infor­ma­tion and prac­tice pro­gram for stu­dents and young doc­tors. This pro­gram was held 12 times at dif­fer­ent anes­the­sia depart­ments in dif­fer­ent hos­pi­tals. Eval­u­a­tion was obtained through a feed­back ques­tion­naire at the end of each ses­sions and with anoth­er ques­tion­naire 2 to 4 years after the program.
Results: Feed­back showed pos­i­tive respons­es con­cern­ing util­i­ty for prac­ti­cal work, actu­al­i­ty, and rel­e­vance for dai­ly prac­ti­cal work. There was a 22.7% response from par­tic­i­pants for the fol­low-up ques­tion­naire. Of these, 87% stat­ed that inter­est in anes­the­sia was increased by the pro­gram, and 74% under­went prac­ti­cal train­ing in an anes­the­sia depart­ment. Sev­en­teen par­tic­i­pants start­ed a spe­cial­i­ty train­ing for anes­the­sia and inten­sive care medicine.
Con­clu­sions: The design of this prac­tice-ori­ent­ed pro­gram was effec­tive in elic­it­ing, spread­ing, and increas­ing inter­est and attract­ing stu­dents to a med­ical specialty.

Key words : Anes­the­si­ol­o­gy, Human resources, Lack of per­son­nel, Spe­cial­i­ty train­ing, Train­ing program

Intro­duc­tion

The scope of spe­cial­i­ty anes­the­sia and inten­sive care med­i­cine has recent­ly con­sid­er­ably changed. Today, the spe­cial­ty includes not only core com­pe­tence of treat­ing the patient in the oper­at­ing room but also, in most coun­tries, post­op­er­a­tive inten­sive care treat­ment, emer­gency med­i­cine and resus­ci­ta­tion, and pain man­age­ment. In Aus­tria, this devel­op­ment togeth­er with the imple­men­ta­tion of the Euro­pean Work­ing Time Direc­tive for Med­ical Doc­tors has led to a dou­bling of the num­ber of anes­thetists in the past 20 years.¹ How­ev­er, as prog­nos­tic eval­u­a­tions point out, even this increase is not suf­fi­cient to cov­er the future need for doc­tors in this spe­cial­i­ty. In Europe, this will be fur­ther aggra­vat­ed by the fact that many anes­thetists are near­ing retirement.

In the King­dom of Sau­di Ara­bia, the prob­lem is urgent. Anes­the­sia is regard­ed as a spe­cial­i­ty that requires hard work but pro­vides only small rewards; this spe­cial­ty has not been able to com­pete with spe­cial­i­ties that allow future doc­tors bet­ter income and the sat­is­fac­tion of a clin­ic for man­ag­ing treat­ment and fol­low­ing patients through­out their dis­ease course. With the ris­ing impor­tance of anes­the­sia and inten­sive care med­i­cine, income lev­els have increased con­sid­er­ably; how­ev­er, inter­est among med­ical stu­dents and grad­u­ates remains low. Thus, attract­ing new stu­dents to this spe­cial­ty will require high efforts in the recruit­ment of grad­u­ates from med­ical uni­ver­si­ties so that the sup­ply of spe­cial­ists for anes­the­sia and inten­sive care meet the num­ber required to allow this need­ed func­tion to con­tin­ue in the med­ical system.

In an effort to study and improve strate­gies to increase the inter­est in this spe­cial­i­ty, we inves­ti­gat­ed the fol­low­ing aspects: (1) fac­tors influ­enc­ing the deci­sion of med­ical stu­dents and grad­u­ates for the selec­tion of a spe­cial­i­ty; and (2) design and eval­u­a­tion of a pro­gram to increase inter­est in the spe­cial­i­ty of anes­the­sia and inten­sive care medicine.

Mate­ri­als and Methods

This study was con­duct­ed in Vien­na, Aus­tria, where the biggest med­ical uni­ver­si­ty of Aus­tria is locat­ed. The Vien­na Hos­pi­tal Ser­vice allowed and sup­port­ed the study to take place in one of the hos­pi­tals. In Aus­tria, the spe­cial­i­ty of anes­the­sia auto­mat­i­cal­ly includes the spe­cial­i­ty of inten­sive care medicine.

In a first step, we eval­u­at­ed the recog­ni­tion of the spe­cial­i­ty in stu­dents and the wish­es of stu­dents with regard to future work­ing con­di­tions by means of semi­struc­tured inter­views. We used these results to design a pro­gram for the recruit­ment of young grad­u­ates and stu­dents. Results from this pro­gram were eval­u­at­ed and com­pared with results from recent pub­li­ca­tions to extract com­mon aspects and con­di­tions in the pic­ture of the spe­cial­i­ty and to allow an objec­tive com­mu­ni­ca­tion of the pros and cons of the spe­cial­i­ty as well as the devel­op­ment of prac­ti­cal means for the recruit­ment of anesthetists.

Inter­views regard­ing the per­cep­tion of the speciality
To deter­mine fac­tors influ­enc­ing the deci­sion for the selec­tion of a spe­cial­i­ty among med­ical stu­dents, we used a ques­tion­naire to con­duct semi­struc­tured inter­views among ran­dom­ly select­ed stu­dents (n = 20; medi­an age of 23 y, 8 male and 12 female par­tic­i­pants) We searched for fac­tors influ­enc­ing inter­est and attrac­tive­ness in the process of deci­sion of a med­ical speciality.

Focus:Practice Pro­gram
We used the Focus:Practice© Pro­gram (a prod­uct of Health Care Com­mu­ni­ca­tion) in the devel­op­ment and imple­men­ta­tion of a pro­gram to improve inter­est among med­ical stu­dents and grad­u­ates for spe­cial­i­ty anes­the­sia and inten­sive care med­i­cine; the pro­gram was based on results from the inter­view stage. All par­tic­i­pants gave writ­ten con­sent to use of their data in anonymized form for doc­u­men­ta­tion and pub­li­ca­tion. The goal of the pro­gram was to give par­tic­i­pants a broad view of the spe­cial­i­ty in order to increase the attrac­tive­ness of the pro­gram and to moti­vate stu­dents to opt for this speciality.

Four top­ics were select­ed: (1) prac­ti­cal pain man­age­ment, (2) peri­op­er­a­tive anaes­the­sia, (3) peri­op­er­a­tive inten­sive care med­i­cine, and (4) emer­gency man­age­ment. The dura­tion of each Focus:Practice lec­ture was 4 hours and was offered at sev­er­al anes­the­sia depart­ments in Vien­na, Aus­tria. The num­ber of par­tic­i­pants was lim­it­ed to 30. Each event con­sist­ed of 3 parts. In part 1, there were 3 or 4 pre­sen­ta­tions with a dura­tion of 20 to 25 min­utes and an empha­sis on prac­ti­cal work­ing. In part 2, there was hands-on train­ing at 3 to 4 dif­fer­ent loca­tions where par­tic­i­pants had the pos­si­bil­i­ty of expe­ri­enc­ing and train­ing dif­fer­ent tech­niques rel­e­vant to the top­ic (eg, air­way man­age­ment, intraosseous access for appli­ca­tion of drugs, and dif­fer­ent appli­ca­tions of ultra­sonog­ra­phy). For this part, par­tic­i­pants were divid­ed into small groups and rotat­ed between loca­tions to allow opti­mal par­tic­i­pa­tion in the train­ing. Part 3 con­sist­ed of a debrief­ing to allow a dis­cus­sion of the con­tents and expe­ri­ences with the ref­er­ents. Ref­er­ents were anes­thetists from dif­fer­ent depart­ments of the Vien­na hospitals.

Extra pre­sen­ta­tions were offered on the top­ics “car­dio­vas­cu­lar anes­the­sia” and “moth­er and child, anes­the­sia in obstet­rics and neona­tal resuscitation.”

All events were offered on the home­page of the student’s asso­ci­a­tion of the Med­ical Uni­ver­si­ty of Vien­na. All par­tic­i­pants were offered a prac­tice turn in one of the par­tic­i­pat­ing anes­the­sia depart­ments to fur­ther increase their knowl­edge of the speciality.

Eval­u­a­tion of the program
All par­tic­i­pants received an eval­u­a­tion ques­tion­naire at the end of each event. Here, they could rate dif­fer­ent aspects of the event on a scale from 1 (worst val­ue) to 5 (best val­ue). They could also add free com­ments on the eval­u­a­tion sheet. The ques­tion­naires were com­plet­ed at the loca­tion and were imme­di­ate­ly hand­ed over to the orga­ni­za­tion team.

To inves­ti­gate whether an eval­u­a­tion from a par­tic­i­pant was not a momen­tary impres­sion and whether the pro­gram elicit­ed a sus­tained val­ue for their deci­sion of a fur­ther career, we per­formed a sec­ond eval­u­a­tion from March 2020 to May 2020 by E‑mail, where we ques­tioned whether any of the par­tic­i­pants com­plet­ed a prac­tice turn in an anes­the­sia depart­ment or whether they had decid­ed on that spe­cial­i­ty. The online ques­tion­naire con­sist­ed of 4 ques­tions and the pos­si­bil­i­ty of free comments.

All data from par­tic­i­pants were strict­ly anony­mous and with their con­sent; no data con­cern­ing the health of the par­tic­i­pants were not­ed, and no inclu­sion of a par­tic­i­pant was due to a dis­ease. In addi­tion, none of the par­tic­i­pants was from a vul­ner­a­ble group as defined in the Helsin­ki Dec­la­ra­tion. The Insti­tu­tion­al Review Board did not clas­si­fy this inves­ti­ga­tion as a clin­i­cal study and made no objec­tions to the per­for­mance of our work.

Results

The num­ber of appli­ca­tions exceed­ed the pos­si­ble num­ber of par­tic­i­pants by 4‑fold. A total of 186 par­tic­i­pants were accept­ed, who could apply for par­tic­i­pa­tion in sev­er­al events, with the total num­ber of par­tic­i­pants in the 12 events per­formed between 2016 and 2018 of 331.

Inter­views with students
Prac­ti­cal work­ing, the wide spec­trum of the spe­cial­i­ty, and the care of patients in emer­gen­cies were named by the stu­dents in the inter­views as argu­ments for choos­ing anes­the­sia. Fur­ther pos­i­tive aspects were the “high-tech” work­ing field, the high num­ber of avail­able posi­tions, and the inter­dis­ci­pli­nary work, espe­cial­ly in the oper­a­tion room. A high homo­gene­ity was also found in answers on fac­tors that ham­pered the choice of anes­the­sia: a lack of knowl­edge about pos­si­bil­i­ties of work and career in the spe­cial­i­ty and a gen­er­al lack of con­tact with anes­the­sia and inten­sive care dur­ing the uni­ver­si­ty train­ing. Fur­ther­more, a lack of train­ing posi­tions, the depen­dance of work and career in a hos­pi­tal, and the lack of com­mu­ni­ca­tion and fol­low-up with patients were also named.

Results of eval­u­a­tion of events
Feed­back data col­lect­ed at the end of the events showed very pos­i­tive respons­es. Aver­age sat­is­fac­tion through­out all events con­cern­ing the items rel­e­vant to prac­ti­cal work and actu­al­i­ty was 4.83. Hands-on train­ing feed­back received a score of 4.80 (Table 1).

The pos­i­tive results were also sup­port­ed by the free com­ments added by the par­tic­i­pants in the feed­back pro­to­cols. A total of 118 par­tic­i­pants added remarks, and 103 par­tic­i­pants (87.3%) empha­sized a high degree of pos­i­tiv­i­ty toward clin­i­cal work in the pre­sen­ta­tions and the hands-on train­ing. The pos­si­bil­i­ty for prac­ti­cal expe­ri­ence and the interdi­sciplinary approach were also highlighted.

Results of the 2020 fol­low-up evaluation
The results of the fol­low-up eval­u­a­tions are shown in Table 2. Of the 186 par­tic­i­pants, 172 (92.5%) had a valid E‑mail address. Of these, 39 par­tic­i­pants (22.7%) respond­ed to the request for fol­low-up at 2 to 4 years after the orig­i­nal events, with 97.5% respond­ing a very pos­i­tive (82%) or pos­i­tive rec­ol­lec­tion of the event. Of respond­ing par­tic­i­pants, 87% stat­ed that the event had influ­enced their inter­ests for this spe­cial­i­ty very pos­i­tive­ly (49%) or pos­i­tive­ly (38%). Of note, 74% of these respon­dents com­plet­ed a prac­ti­cal train­ing in a depart­ment of anes­the­sia or inten­sive care. The final ques­tion (“Did you decide for the spe­cial­ties of anaes­the­sia and inten­sive care?”) was answered with “yes” by 17 par­tic­i­pants (43.6%), amount­ing to 10% of total par­tic­i­pants (n = 172) with a still valid E‑mail account. Anoth­er 20.5% had not yet tak­en the deci­sion. In the area ded­i­cat­ed to free com­ments, mul­ti­ple remarks were made on the val­ue and the sus­tained effect of hands-on training.

Dis­cus­sion

Results of our eval­u­a­tion demon­strat­ed that inter­est among stu­dents and young grad­u­ates can be great­ly improved by the con­cept of the Focus:Practice Pro­gram. Infor­ma­tion rel­e­vant to the prac­ti­cal work and con­tent of the spe­cial­i­ty was great­ly wel­comed by the par­tic­i­pants. The events that were devel­oped with sug­ges­tions from the ini­tial ques­tion­naire, which includ­ed the sug­ges­tion of hands-on train­ing, had a very pos­i­tive effect on inter­est for the spe­cial­ty among par­tic­i­pants, which led to a num­ber of stu­dents decid­ing to train in anes­the­sia and inten­sive care medicine.

To ensure a suf­fi­cient num­ber of anes­thetists for deliv­ery of med­ical care, improve­ments in the image of anes­the­sia are need­ed, espe­cial­ly among grad­u­ates and med­ical stu­dents. Con­tact with this spe­cial­i­ty is sparse in many coun­tries, and the impres­sion often deliv­ered is that of dull but very hard work with few rewards. How­ev­er, stud­ies have shown that the infor­ma­tion avail­able to med­ical stu­dents is extreme­ly impor­tant for their future deci­sion on which spe­cial­i­ty to choose.² Thus, it is essen­tial to sup­ply med­ical stu­dents a com­pre­hen­sive view of mod­ern anes­the­sia and inten­sive care med­i­cine as a com­plex and broad field of work.

For Aus­tria, the pres­i­dent of the Aus­tri­an Soci­ety for Anaes­the­si­ol­o­gy, Inten­sive Care Med­i­cine, and Rean­i­ma­tol­ogy (ÖGARI) addressed the impor­tance of this prob­lem in a pre­sen­ta­tion at the 2019 Aus­tri­an Inter­na­tion­al Con­gress (Graz, Aus­tria). Mea­sures are urgent­ly need­ed against the impend­ing short­age of anes­thetists and are receiv­ing the high­est pri­or­i­ty to avoid a seri­ous threat to med­ical care.³ An inves­ti­ga­tion by BDO Health Care Con­sul­tan­cy, which was man­dat­ed by ÖGARI and pre­sent­ed to the direc­tors of Aus­tri­an anes­the­sia depart­ments, con­clud­ed that imme­di­ate mea­sures are need­ed to ensure con­tin­ued demand for anes­thetists. This was also empha­sized in a posi­tion paper of the ÖGARI.⁴

In Sau­di Ara­bia, the sit­u­a­tion is almost the same. Active mea­sures are need­ed to encour­age new grad­u­ates to choose train­ing in anes­the­sia and inten­sive care med­i­cine. The short­ages for these spe­cial­i­ty are more than for any oth­er coun­try. More than 90% of inten­sivists and anes­the­si­ol­o­gists in Sau­di Ara­bia are not Sau­di citizens.

A sur­vey of the Aus­tri­an Board of Med­ical Doc­tors showed that young doc­tors who had decid­ed upon anes­the­sia as a spe­cial­ty were rat­ing their train­ing on aver­age much high­er than young doc­tors in oth­er specialities.5 Thus, if the train­ing itself has this pos­i­tive image, the prob­lem must be faced ear­li­er in the process, that is, when stu­dents are decid­ing upon their spe­cial­i­ty. Stu­dents and young doc­tors should be giv­en infor­ma­tion in a time­ly man­ner on the broad pos­si­bil­i­ties and the attrac­tive­ness of anes­the­sia, which def­i­nite­ly are in con­trast to the wide­spread image of the spe­cial­i­ty in the pub­lic and among med­ical students.

This is also in accor­dance with many inves­ti­ga­tions from oth­er coun­tries and spe­cial­i­ties.^1,2,6,7 With this knowl­edge, deficits in infor­ma­tion can be cor­rect­ed, pos­si­bil­i­ties can be high­light­ed, and old and wrong images of the spe­cial­i­ty can be elim­i­nat­ed. The first part of our inves­ti­ga­tion in 20 stu­dents showed a deficit in knowl­edge on prac­ti­cal pos­si­bil­i­ties owned by the spe­cial­i­ty and espe­cial­ly a lack of con­tact with anes­the­sia and inten­sive care dur­ing train­ing at the uni­ver­si­ty. This result is in accor­dance with a study from the Uni­ver­si­ty of Bochum, which inves­ti­gat­ed the image of mod­ern anes­the­sia in med­ical stu­dents as well as their request for work­ing con­di­tions and their per­cep­tion of the spe­cial­i­ty.² Pio­ntek con­clud­ed that, despite pri­or expe­ri­ences and high sat­is­fac­tion with lec­tures in anes­the­sia and inten­sive care med­i­cine, the spe­cial­i­ty is still pre­dom­i­nant­ly iden­ti­fied with the work in the oper­at­ing room and only to a less­er degree with inten­sive care med­i­cine, emer­gency med­i­cine, and pain man­age­ment. Pio­ntek sug­gest­ed inten­si­fy­ing com­mu­ni­ca­tions on the image of mod­ern anes­the­sia for the fur­ther devel­op­ment of the spe­cial­i­ty.²

In their inves­ti­ga­tion of emer­gency med­i­cine, Chew and col­leagues eval­u­at­ed 800 respons­es to ques­tion­naires and con­clud­ed that ear­ly con­tact with a spe­cial­i­ty is impor­tant for the deci­sion to choose a spe­cial­i­ty.⁸ Thus, efforts are need­ed toward pro­vid­ing stu­dents oppor­tu­ni­ties to become acquaint­ed with dif­fer­ent spe­cial­i­ties and to sup­port their deci­sion by prac­ti­cal knowledge.

Dur­ing appli­ca­tion of results obtained dur­ing the first part of our study, we found it was pos­si­ble to devel­op a pro­gram that focused on prac­tice and insight on broad aspects of a spe­cial­i­ty. In our study, all pre­sen­ta­tions and teach­ings were per­formed by vol­un­teers from par­tic­i­pat­ing depart­ments. Pub­lic­i­ty was orga­nized by the Stu­dents Asso­ci­a­tion of the Med­ical Uni­ver­si­ty of Vien­na and was so suc­cess­ful that 4 times as many appli­ca­tions were received as par­tic­i­pants could be accept­ed. We take this as evi­dence that stu­dents are deeply inter­est­ed and that there is need for such events. Dur­ing feed­back at the end of the event and dur­ing fol­low-up 2 to 4 years after ini­tial par­tic­i­pa­tion, par­tic­i­pants also stat­ed that they val­ued con­tent and prac­tice-relat­ed exercises.

Bias has to be expect­ed with this fol­low-up as the call was only answered by 22.4% of par­tic­i­pants, with answers nat­u­ral­ly more like­ly giv­en by those who kept the event in a more pos­i­tive mem­o­ry. How­ev­er, 17 of our par­tic­i­pants had cho­sen at that point (2 to 4 years fol­low­ing the event) to accept a train­ing posi­tion in a depart­ment of anes­the­sia and inten­sive care med­i­cine, account­ing for almost 10% of par­tic­i­pants. Although some may have already had inter­est in anes­the­sia before join­ing our pro­gram, the effect of the pro­gram was pos­i­tive by either ampli­fy­ing their wish or by cor­rect­ing wrong expec­ta­tions, which some par­tic­i­pants may have had and which could have caused them to leave the train­ing prematurely.

Con­clu­sions

We found that our pro­gram was suc­cess­ful in elic­it­ing and spread­ing inter­est for anes­the­sia and inten­sive care med­i­cine and that a con­sid­er­able num­ber of stu­dents and young doc­tors were sup­port­ed in their deci­sion for anes­the­sia and inten­sive care medicine.

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